Big Experiences Through Small Means

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By: China Cox

As residents, we spend a good amount of time talking about our hospital ward experience at the small community hospital that serves as our primary residency home. The place has its quirks including the people, processes, semi paper charting, an urban patient population, etc (+/- ghosts). As much as it drives us crazy sometimes, I often find the small hospital provides us with experiences that we would not get in larger institutions.

pina-messina-464947.jpgThis week I got really frustrated on the inpatient medicine service–a rotation where I usually feel useful, busy, and at home. We had a near capped team, but my list was full of consult patients. We admitted them to the medicine service, but general surgery, infectious disease, or cardiology were really running the show. I would see all of my patients early before the consultants rounded and was unable to offer them any but the vaguest of updates. “Well, I’m going to check in with Dr. ID and see if we can transition you to oral antibiotics yet.” “Well, I haven’t heard back from Dr. GenSurg yet. He’s waiting on the final read from Dr. Radiology to make a surgical plan.” “Well, yesterday Dr. Cards mentioned a stress test. I’ll further clarify with them today which kind.” “No you can’t eat breakfast, I’m sorry. Why? In case you have a procedure later.”

It was terrible! My biggest contribution of the day was electrolyte repletion. I felt at a complete loss and the frustration made me crabby with my co-intern, which is never ok.

Then the day turned around. The cardiologist who had been short with me earlier walked into our workroom and asked if I wanted to electrically cardiovert our new onset a-fib patient. He walked me through every step including “if-then bad outcome/what to do next” scenarios. The patient converted to normal sinus rhythm without complications–a win!

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I walked out of that procedure and sat down with our infectious disease attending who was sitting at the main nursing station. I had been trying to catch him in person for three days. We talked through each of the patients we shared. We looked at cultures, speciation, and susceptibilities. We conferred with the micro lab, and then we made long-term antibiotic plans for our ICU patient who was intubated because of pneumonia superimposed on the flu.

I called the regional university hospital lab to send out lab results on a Saturday and was able to confirm that our fever of unknown origin patient with HIV/AIDS was negative for opportunistic infections. Ultimately he needed seven days of antibiotics for acute bacterial sinusitis and could be discharged that day.

The cardiologist with whom I had cardioverted earlier called to tell us that our patient with bilateral foot osteomyelitis had a large valvular vegetation visible on his echocardiogram, which had most likely shot septic emboli to his toes, causing the original necrosis. As the primary team, we had thought ordering the echocardiogram was a stretch. This result was a huge learning point from infectious disease. Later I joined the podiatrist to evaluate those feet and learned about the planned surgical steps and the wound care that would be required after amputation.

Our last common ID patient was an IV drug user who needed long-term antibiotics for septic arthritis and MRSA bacteremia. When the attending posed antibiotics plans, I would intermittently respond with “yes, but that is not realistic for him: He can’t afford it”, “He can’t make it to outpatient IV drug infusion appointments”, “It’s not going to work.” Dr. ID talked to me for ten minutes at the end of a long day about our responsibility as physicians to propose the right treatment, not the realistic treatment. Once the hospital accepted this patient for care it became our responsibility to provide appropriate treatment no matter the likelihood that the hospital would get compensation for that care.

As an internal medicine resident at a large university hospital, I would get cardiology procedure experience on cardiology. I would get to spend long periods of time with the ID faculty only if I were on an infectious disease rotation. I would probably never get very much experience with podiatry at all, and I am not sure how much of the faculty would take the time at 5 pm to talk about our ethical responsibilities. Our family medicine residency offers me these learning opportunities in ONE afternoon because we train in a small community hospital. Despite the frustrations that can come with being a smaller facility (and the possible ghosts), I wouldn’t want to train anywhere else.

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China Cox, MD, is a current resident at the University of Utah. She graduated from Clemson University and then attended medical school at The Medical University of South Carolina. Her medical interests include Geriatric medicine, reproductive health, and alternative models of care, and outside of medicine, China enjoys container gardening, live music, and rock climbing. 


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